The results are in from the only completed Adrenaline (Epinephrine in non-Commonwealth countries) vs. Placebo for Cardiac Arrest study.

Even I overestimated the possibility of benefit of epinephrine.

I had hoped that there would be some evidence to help identify patients who might benefit from epinephrine, but that is not the case.

PARAMEDIC2 (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) compared adrenaline (epinephrine) with placebo in a “randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest”.

More people survived for at least 30 days with epinephrine, which is entirely expected. There has not been any controversy about whether giving epinephrine produces pulses more often than not giving epinephrine. As with amiodarone (Nexterone and Pacerone), the question has been whether we are just filling the ICUs and nursing home beds with comatose patients.

There was no statistical evidence of a modification in treatment effect by such factors as the patient’s age, whether the cardiac arrest was witnessed, whether CPR was performed by a bystander, initial cardiac rhythm, or response time or time to trial-agent administration (Fig. S7 in the Supplementary Appendix).[1]

The secondary outcome is what everyone has been much more interested in – what are the neurological outcomes with adrenaline vs. without adrenaline?

The best outcome was no detectable neurological impairment.

the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment.

Our work with patients and the public before starting the trial (as summarized in the Supplementary Appendix) identified survival with a favorable neurologic outcome to be a higher priority than survival alone.[1]

Click on the image to make it larger.

Are there some patients who will do better with epinephrine than without?

Maybe (I would have written probably, before these results), but we still do not know how to identify those patients.

Is titrating tiny amounts of epinephrine, to observe for response, reasonable? What response would we be looking for? Wat do we do if we observe that response? We have been using epinephrine for over half a century and we still don’t know when to use it, how much to use, or how to identify the patients who might benefit.

I will write more about these results later

We now have evidence that, as with amiodarone, we should only be using epinephrine as part of well controlled trials.

As part of a study to find out if epinephrine (adrenaline in Commonwealth countries) is safe to use in cardiac arrest, a patient was treated with a placebo, rather than the inadequately tested drug. Some people are upset that the patient did not receive the drug they know nothing about.[1]

The critics are trying to make sure that we never learn.

We need to find out how much harm epinephrine causes, rather than make assumptions based on prejudices.

When used in cardiac arrest, does epinephrine produce a pulse more often?

Yes.

When used in cardiac arrest, does epinephrine produce a good outcome more often?

We don’t know.

In over half a century of use in cardiac arrest, we have not bothered to find out.

We did try to find out one time, but the media and politicians stopped it.[2]

We would rather harm patients with unreasonable hope, than find out how much harm we are causing to patients.

We would rather continue to be part of a huge, uncontrolled, unapproved, undeclared, undocumented, unethical experiment, than find out what works.

Have we given informed consent to that kind of experimentation?

Ignorance is bliss.

The good news is that the enrollment of patients has finished, so the media and politicians will not be able to prevent us from learning the little that we will be able to learn from this research.[3]

Will the results tell us which patients are harmed by epinephrine?

Probably not – that will require a willingness to admit the limits of what we learn and more research.

What EMS treatments have been demonstrated to improve outcomes from cardiac arrest?

1. High quality chest compressions.2. Defibrillation, when indicated.

Nothing else.

All other treatments, when tested, have failed to be better than nothing (placebo).

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

Trial Update – 19 February 2018:
PARAMEDIC2 has finished recruitment and we are therefore no longer issuing ‘No Study’ bracelets. The data collected from the trial is in the process of being analysed and we expect to publish the results in 2018. Once the results have been published, a summary will be provided on the trial website.

–

Edited 12-27-2018 to correct link to pdf of Jacobs study in footnote 2.

This is a nice study, which unfortunately ran into problems with enrollment and funding. There are some things that I think should have been done differently.

The doses of chilled IV (IntraVenous) fluid were not weight-based, while the fluid in the human body is weight-based. If midazolam (Versed) was given, the dose was just a single dose of 5 mg, or 2 doses of 5 mg each. The effects of midazolam are much less weight-based, than fluid, but the appropriate way to administer midazolam is to titrate to effect. Even if administering 10 mg of midazolam produces the desired effect in 80%, or 90%, of patients, that can still leave a significant portion inadequately sedated. The goal of TTM (Targeted Temperature Management) may be defeated by the movement of an even mildly agitated patient.

Would another drug, such as ketamine, be more appropriate? How much does use of midazolam affect the use of pressors to counter the vasodilatory effects of midazolam? Unlike other sedatives, ketamine does not seem to produce vasodilation and/or depress cardiac activity. The midazolam was only mentioned in the description of the study interventions and only described as being given to prevent shivering, so the dose may be adequate, but there is only the one mention in the entire paper.

The fluid administration was shown to be different with a p value of <0.0001. The difference is only 170 ml (5 3/4 oz), so it is a distinction described as significant by p value, but it does not appear to be a significant difference in any way that would affect patients. The SD (Standard Deviation - how much variability exists in about 2/3 of patients) is the same as the amount of fluid given to the control group and 2 3/4 times the amount of the difference. In other words, there was a lot of overlap in the volumes administered to the patients in the two groups.
While the p value of <0.0001 suggests confidence in the results being due to change only one time in 10,000, that is misleading.

Total fluid infused was not documented for 98 (35%) patients who received Prehospital Cooling and 121 (40%) control patients.[1]

The raw data on the volumes is not included, nor is the shape of the graph of distribution of the volumes, but it looks as if 20%, or 30%, of the control group may have received more fluid that the intervention group – and then there are the more than 35% of patients without documentation of fluid volumes.

Since the amount of difference is small, it does not seem to matter, but the intervention group was forcing the chilled fluid into the patients with pressure bags, so why so little difference between the groups?

How long does it take to administer 170 ml of chilled IV fluid by pressure infusion? Does it take longer than it takes to get from the ambulance to the hospital stretcher?

That is just a statistical oddity that is not going to affect outcomes.

The next may be the true the significant finding of the study.

Patients in the prehospital cooling group were more likely to (ever) receive TTM in hospital [190 (68%) vs 170 (56%); RR 1.21, p = 0.003] than patients in the control group.[1]

TTM (Targeted Temperature Management) is the new term for therapeutic hypothermia, which has been shown to be effective.

If not, why not?

Across all studies that used conventional cooling methods rather than no cooling (three studies; 383 participants), we found a 30% survival benefit (RR 1.32, 95% CI 1.10 to 1.65). The quality of the evidence was moderate.[2]

With no difference in the rhythms of the control group and the intervention group, why the difference in the rate of TTM in the hospital?

Will this be similar to the case of waveform capnography? EMS ended up pressuring many/some EDs to begin to use EtCO2 on all intubated patients. This was a change from the previous, much too common, ED practice of complaining about and pulling at the EtCO2 tubing, because it was an unknown item that was in the way.

EMS should not need to encourage the ED to provide better care, especially about treatments/assessments that originated as in-hospital treatments/assessments. It should be the reverse.

There is an excellent review of TTM research at Life In The Fast Lane.[3]

I didn’t write a lot in 2016, but 2016 may have been the year we put the final nail in the coffin of amiodarone. Two major studies were published and both were very negative for amiodarone.

If we give enough amiodarone to have an effect on ventricular tachycardia, it will usually be a negative effect.[1]

Only 38% of ventricular tachycardia patients improved after amiodarone, but 48% had major adverse cardiac events after amiodarone.

There are better drugs, including adenosine, sotalol, procainamide, and ketamine for ventricular tachycardia. Sedation and cardioversion is a much better choice. Cardioversion is actually expected after giving amiodarone.

For cardiac arrest, amiodarone is not any better than placebo or lidocaine. What ever happened to the study of amiodarone that was showing such wonderful results over a decade ago? It still hasn’t been published, so it is reasonable to conclude that the results were negative for amiodarone. It is time to make room in the drug bag for something that works.[2],[3]

On the other hand, now that we have improved the quality of CPR by focusing on compressions, rather than drugs, more patients are waking up while chest compressions are being performed, but without spontaneous circulation, so ketamine has another promising use. And ketamine is still good for sedation for intubation, for getting a patient to tolerate high flow oxygen, for agitated delirium, for pain management, . . . .[4],[5]

Masimo’s RAD 57 still doesn’t have any evidence that it works well on real patients.[6]

When intubating, breathe. Breathing is good. Isn’t inability to breathe the reason for intubation?[7]

This is a very interesting trial that may surprise the many outspoken amiodarone advocates, but it should not surprise anyone who pays attention to research.

ALPS showed that we should stop giving amiodarone for unwitnessed shockable cardiac arrest. The lead researcher is still trying to spin amiodarone for witnessed shockable cardiac arrest, even though the results do not show improvement in the one outcome that matters – leaving the hospital with a brain that still works.[1],[2],[3]

One problem with the study that they do not address on the podcast is that the patients in the study appear to have had time to watch Casablanca before treatment started. Here’s looking at you, while we’re waiting, kid. This is apparently unintentional one way of doing a placebo washout. If we wait long enough . . . .

Time from arrival to start of infusion was 87 ± 21 min for procainamide and 115 ± 36 min for amiodarone patients (P = 0.58).[4]

If nothing else, this demonstrates how little we need to worry about immediately pushing drugs for stable monomorphic VT (V Tach or Ventricular Tachycardia). Should we expect much from antiarrhythmic treatment?

Research shows that for stable monomorphic VT (V Tach or Ventricular Tachycardia) amiodarone is not very likely to be followed by an improvement. Only 29%[5] or only 25%[6] or only 15% within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29%.[7] For those of you who are not good at math, that means amiodarone is about the same as doing nothing, only it comes in a syringe. Even though these poor outcomes ignore the side effects, they are the best evidence in favor of amiodarone, so what Kool-Aid are the advocates drinking?

Adenosine, yes adenosine the SVT (SupraVentricular Tachycardia) drug, appears to be more effective at treating ventricular tachycardia than amiodarone – and adenosine is faster and safer than amiodarone.[8]

What if the patient becomes unstable? First start an IV (IntraVenous) line. Then sedate the patient. Then apply defibrillator pads. After the patient is adequately sedated, then cardiovert. We do not need the pads on the patient first. If it takes a while to put the pads on, that is a problem with the ability of the doctors and nurses, not a medical problem.

It does not appear as if any patient received amiodarone or procainamide until after waiting in the ED (Emergency Department) for over an hour. Were some patients cardioverted in well under an hour? Probably. The important consideration is that the doctors and nurses be able to apply the defibrillator pads properly and quickly and deliver a synchronized cardioversion in less than a minute. If the patient has not yet been sedated, the cardioversion should be delayed until after the patient is adequately sedated, so the intervention that depends most on time is the sedation of the patient.

Is there a better treatment than amiodarone? Sedate the patient before the patient becomes unstable, then cardiovert. How do the MACEs (Major Adverse Cardiac Events) compare with sedation and cardioversion vs. antiarrhythmic treatment.

5.4 Proarrhythmia
Amiodarone may cause a worsening of existing arrhythmias or precipitate a new arrhythmia. Proarrhythmia, primarily torsade de pointes (TdP), has been associated with prolongation, by intravenous amiodarone, of the QTc interval to 500 ms or greater. Although QTc prolongation occurred frequently in patients receiving intravenous amiodarone, TdP or new-onset VF occurred infrequently (less than 2%). Monitor patients for QTc prolongation during infusion with amiodarone. Reserve the combination of amiodarone with other antiarrhythmic therapies that prolong the QTc to patients with life-threatening ventricular arrhythmias who are incompletely responsive to a single agent.[9]

All antiarrhythmic drugs can cause arrhythmias. In the absence of information about a specific problem that is best addressed by a specific drug (amiodarone is the opposite of specific), we should avoid treatments that have such a high potential for harm.

Amiodarone doesn’t even do a good job of preventing arrhythmias.

Intravenous amiodarone did not prevent induction of sustained ventricular tachycardia in any of five patients inducible at baseline. Of six patients with non-sustained ventricular tachycardia, five had sustained ventricular tachycardia or fibrillation induced after amiodarone infusion.[10]

Is anything worse than amiodarone? Even epinephrine, yes epinephrine the inadequately tested cardiac arrest drug, has been followed by improved outcomes from V Tach after amiodarone failed.[11]

What is best for the patient?

Sedation, search for reversible causes, apply defibrillator pads, and be prepared to cardiovert.

Maybe sedation isn’t that important? This is by Dr. Peter Kowey, one of the top cardiologists in the world.

The man’s very first utterance was, “If it happens again, just let me die.”

As I discovered, the reason for this patient’s terror was that he had been cardioverted in an awake state. Ventricular tachycardia had been relatively slow, he had not lost consciousness, and the physicians, in the heat of the moment, had not administered adequate anesthesia. Although the 5 mg of intravenous diazepam had made him a bit drowsy, he felt the electric current on his chest and remembered the event clearly.

For sedation, I would recommend ketamine, but etomidate was recommended in the podcast. Both work quickly and the most important obstacle to immediate treatment of a patient who suddenly deteriorates is the time to effect of sedation. Neither drug is expected to interfere with perfusion, which is the main excuse given for avoiding sedation for cardioversion.

This study is very small (not the fault of the authors), but it adds to the evidence that amiodarone is not a good first treatment for the patient.

I have been meaning to write about this ketamine study, but Greg Friese wrote about one of the comments on a review of the paper –

Most intriguing is this reader comment “talk to your damn patients calm them down and you can avoid this knee jerk, sedate first ask questions later whilst risking side effects, response ,that seems to be coming the norm” which seems disconnected to the actual syndrome of ExDS and the danger to medics, cops, and the patient when a patient’s behavior is out of control.[1]

Intriguing?

The review was by Dr. Ryan Radecki of Emergency Medicine Literature of Note (the best quick and to the point reviews of research I know of on line). Did Dr. Radecki even suggest that we should avoid attempts at talking the patient down?

From the land of “we still have droperidol”, this case series details the use of ketamine as “rescue” treatment for “agitated delirium”. In lay terms, the situation they’re describing is the utterly bonkers patient being physically restrained by law enforcement for whom nothing else has worked.[2]

No.

Did the authors of the original paper suggest that we should avoid attempts at talking the patient down (verbal de-escalation)?

The sedation of agitated and aggressive patients in the emergency department (ED) and other acute care areas is a major problem for health care workers. Patients with acute behavioral disturbance may respond to verbal de-escalation or oral sedation, but a substantial proportion of this group requires parenteral sedation and mechanical restraint.1, 2, 3, 4, 5[3]

How many patients can be managed by just talking them down? Should we avoid preparation for chemical and physical restraints, just because we are trying to talk the patient down?

There is indirect evidence from pharmacologic studies of agitation that verbal techniques can be successful in a substantial percentage of patients. In a recent study, patients were excluded from a clinical trial of droperidol if they were successfully managed with verbal de-escalation; however, the specific verbal de-escalation techniques were not identified or studied.12[5]

Research on chemical management of excited delirium should not be interpreted as discouraging us from talking patients down.

Clinicians who work in acute care settings must be good multitaskers and tolerate rapidly changing patient priorities. In this environment, tolerating and even enjoying dealing with agitated patients takes a certain temperament, and all clinicians are encouraged to assess their temperament for this work.[5]

There is a lot of good information in the article, but approaching every patient with the expectation that verbal de-escalation will work is unrealistic. A lack of preparation sets everyone up for a worse outcome in the cases where verbal de-escalation does not work. Injuries and death become more likely, when we are not prepared to switch to sedation and have only physical restraint to respond to rapidly changing patient priorities.

We need to be able to adapt to the agitated patient. Verbal de-escalation and excited delirium do not get enough attention. This paper does not address the use of verbal de-escalation, because the enrolled patients had to fail to respond to other chemical sedation first. The patients who failed chemical sedation are also the ones who failed to respond to whatever attempts at verbal de-escalation were used.

The short answer – The Advanced Cardiac Life Support guidelines could be worse.

How does the American Heart Association determine that a recommendation is not beneficial?

Class III: No Benefit, is a moderate recommendation, generally reserved for therapies or tests that have been shown in high-level studies (generally LOE A or B) to provide no benefit when tested against a placebo or control.[1]

The tobacco enema has been used successfully as a treatment for cardiac arrest, so the evidence of lack of benefit is poor.[2] Clearly, the Advanced Cardiac Life Support guidelines cannot claim that the tobacco enema is Class III. Successfully? The treatment was used and a dead person was no longer dead. In other words, just as successfully as most of the ACLS treatments.

From Eisenberg, MS. Life in the balance: emergency medicine and the quest to reverse sudden death. 1997; Oxford University Press. [betterworldbooks][3]

This is one way to make excuses for justify doing something just because of ideology. In the absence of good evidence of benefit, we should not harm our patients to protect our ideology. We used to do this with blood-letting, which was defended even after there was clear evidence of harm. That is just the best known example, but this dishonesty continues and continues to be defended.

Why don’t we hold anyone accountable, when we have the evidence that our treatments are harmful? Because we all seem to go along to get along.

The 2015 ACLS guidelines are not all bad, but they clearly do not encourage withholding harmful treatments until we have obvious evidence of harm. Should we assume that a treatment works just because the explanation appeals to some experts as much as the explanation for blood-letting appealed to the experts when that was in vogue?

This is not medicine. This is a fashion show. Our patients are the ones harmed.

–

Footnotes:

–

[1]2015 AHA Classes of Recommendation2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 2: Evidence Evaluation and Management of Conflicts of Interest
Development of the 2015 Guidelines Update
Circulation.
2015; 132: S368-S382Free Full Text from Circulation.

Will Pennsylvania continue its trend of rejecting treatments that do not work and medicine that is not medicine?

One place to get a clear indication is the Post-resuscitation Care protocol, which has encouraged testing the ice waters of therapeutic hypothermia as an optional treatment that requires medical command orders. Backing away from further use of cold IV fluid for no known benefit to patients should be easy to do without political backlash from those more interested in doing something than in protecting patients from treatment for the sake of treatment.

Possible Medical Command Orders:

A. In adult patient, cold (4º C) NSS bolus of 20-30 mL/kg, if available, may be ordered if patient not following commands after ROSC from nontraumatic cardiac arrest.[1]

But wait.

I know that therapeutic hypothermia works.

That is misleading. There is plenty of evidence that cooling patients in the hospital improves outcomes, but for prehospital patients the use of cold IV fluids has only been shown to improve outcomes for asystole/PEA (Pulseless Electrical Activity) patients and only in one study.[2]

For the patients most likely to survive cardiac arrest, the initial rhythm is V Fib (Ventricular Fibrillation). For these patients we need to stop the ice water infusions. Prehospital cold IV fluids following resuscitation of V Fib patients has been studied to death – more deaths in the treatment groups than in the no treatment groups. There has been no evidence of any benefit from IV ice water.[3],[4],[5]

This method of administration would probably be better for V Fib patients than IV ice water, because the adverse effects of IV ice water appear to be due to fluid overload.

I do not mean that prehospital therapeutic hypothermia is always a bad idea for V Fib patients – only that we need to find a way that is less harmful than dumping ice water into these recently dead patients for no benefit.

Click on image to make it larger.[3]

First, do no harm.

If the treatment is not beneficial, there is no good reason to expose patients to the adverse effects of the treatment for no known benefit.

Will we stop making excuses for endangering our patients with treatments that do not work?

Science teaches us to learn from our mistakes, while human nature encourages us to make excuses and continue to make the mistakes. Will we make the mistake of continuing to dump cold ice water into these recently dead patients for no good reason?

Ignorance is preferable to error; and he is less remote from the truth who believes nothing, than he who believes what is wrong.

- Thomas Jefferson

Notes on the State of Virginia (1781-1783)

-

Bigotry and science can have no communication with each other, for science begins where bigotry and absolute certainty end. The scientist believes in proof without certainty, the bigot in certainty without proof. Let us never forget that tyranny most often springs from a fanatical faith in the absoluteness of one’s beliefs.

Ashley Montagu.

-

Today we rely less on superstition and tradition than people did in the past, not because we are more rational, but because our understanding of risk enables us to make decisions in a rational mode.

- Peter L. Bernstein

Against the Gods: the remarkable story of risk (1996)

-

Mark my word, if and when these preachers get control of the [Republican] party, and they're sure trying to do so, it's going to be a terrible damn problem. Frankly, these people frighten me. Politics and governing demand compromise. But these Christians believe they are acting in the name of God, so they can't and won't compromise. I know, I've tried to deal with them.

Barry Goldwater.

-

I think every good Christian ought to kick Falwell right in the ass.

Barry Goldwater

Said in July 1981 in response to Moral Majority founder Jerry Falwell's opposition to the nomination of Sandra Day O'Connor to the Supreme Court, of which Falwell had said, "Every good Christian should be concerned." as quoted in Ed Magnuson, "The Brethren's First Sister," Time Magazine, (20 July, 1981)

-

What do you think science is? There's nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. Which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic?

Dr. Steven Novella.

-

What progress we are making. In the Middle Ages they would have burned me. Now they are content with burning my books.

Sigmund Freud (1933)

Today the samizdat is digital and burning a copy has the opposite meaning. A little later, persecution of the Jews was once again the law - Freud's four sisters all died in concentration camps, although not by burning.

-

"Can you prove that it’s impossible?” “No”, I said, “I can’t prove it’s impossible. It’s just very unlikely”. At that he said, “You are very unscientific. If you can’t prove it impossible then how can you say that it’s unlikely?” But that is the way that is scientific. It is scientific only to say what is more likely and what less likely, and not to be proving all the time the possible and impossible. To define what I mean, I might have said to him, "Listen, I mean that from my knowledge of the world that I see around me, I think that it is much more likely that the reports of flying saucers are the results of the known irrational characteristics of terrestrial intelligence than of the unknown rational efforts of extra-terrestrial intelligence." It is just more likely. That is all.

Richard Feynman.

The Character of Physical Law (1965)
chapter 7, “Seeking New Laws,” p. 165-166:

It has been over half century since Feynman explained this. The reports of flying saucers have continued, but there is still no valid evidence to support belief in flying saucers. Feynman's explanation is a good definition of unlikely.

-

An ignorant mind is precisely not a spotless, empty vessel, but one that’s filled with the clutter of irrelevant or misleading life experiences, theories, facts, intuitions, strategies, algorithms, heuristics, metaphors, and hunches that regrettably have the look and feel of useful and accurate knowledge.

David Dunning - explaining the Dunning-Kruger effect.

-

Treat beliefs not as sacred possessions to be guarded but rather as testable hypotheses to be discarded when the evidence mounts against them.

Philip Tetlock.

-

Squatting in between those on the side of reason and evidence and those worshipping superstition and myth is not a better place. It just means you’re halfway to crazy town.

PZ Myers

-

The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

-

Imagine a world in which we are all enlightened by objective truths rather than offended by them.

Neil deGrasse Tyson

-

Education is a progressive discovery of our own ignorance.

Will Durant.

-

You don't use science to show that you're right,

you use science to become right.

Randall Munroe

-

Just because science doesn't know everything doesn't mean you can fill in the gaps with whatever fairy tale most appeals to you.

There appears to be in mankind an unacceptable prejudice in favor of ancient customs and habitudes which allows practices to continue long after the circumstances, which formerly made them useful, cease to exist

Benjamin Franklin.

-

If science proves some belief of Buddhism wrong,

then Buddhism will have to change.

Tenzin Gyatso, 14th Dalai Lama.

-

Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them;

Thomas Jefferson.

-

Science doesn't make it impossible to believe in God.

It just makes it possible to not believe in God.

Stephen Weinberg.

-

There are no forbidden questions in science,

no matters too sensitive or delicate to be probed,

no sacred truths.

Carl Sagan.

-

The legitimate powers of government extend to such acts only as are injurious to others. But it does me no injury for my neighbour to say there are twenty gods, or no god. It neither picks my pocket nor breaks my leg.

Thomas Jefferson.

-

It is better to not understand something true,
than to understand something false.

Neils Bohr.

-

God does not play dice with the universe.

Albert Einstein

Stop telling God what to do with his dice.

response by Neils Bohr.

-

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

Paracelsus.

-

What is not true, as everyone knows, is always immensely more fascinating and satisfying to the vast majority of men than what is true.

H.L. Mencken.

-

Every valuable human being must be a radical and a rebel, for what he must aim at is to make things better than they are.

Niels Bohr.

-

How wonderful that we have met with a paradox. Now we have some hope of making progress.

Niels Bohr.

-

An expert is a man who has made all the mistakes which can be made in a very narrow field.

Niels Bohr.

-

Every sentence I utter must be understood not as an affirmation, but as a question.

Niels Bohr.

-

Some subjects are so serious that one can only joke about them.

Niels Bohr.

-

I have no special talents. I am only passionately curious.

Albert Einstein.

-

Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions.

Albert Einstein.

-

Never memorize what you can look up in books.

Albert Einstein.

-

The prestige of government has undoubtedly been lowered considerably by the prohibition law. For nothing is more destructive of respect for the government and the law of the land than passing laws which cannot be enforced. It is an open secret that the dangerous increase of crime in the United States is closely connected with this.

Albert Einstein.

-

the chance is high that the truth lies in the fashionable direction. But, on the off-chance that it is in another direction - a direction obvious from an unfashionable view of field theory - who will find it? Only someone who has sacrificed himself by teaching himself quantum electrodynamics from a peculiar and unusual point of view; one that he may have to invent for himself. I say sacrificed himself because he most likely will get nothing from it, because the truth may lie in another direction, perhaps even the fashionable one.

If you've made up your mind to test a theory, or you want to explain some idea, you should always decide to publish it whichever way it comes out. If we only publish results of a certain kind, we can make the argument look good. We must publish both kinds of results.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.

Richard Feynman.

-

Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

Science is the belief in the ignorance of experts.

Richard Feynman.

-

The only way to have real success in science, the field I’m familiar with, is to describe the evidence very carefully without regard to the way you feel it should be. If you have a theory, you must try to explain what’s good and what’s bad about it equally. In science, you learn a kind of standard integrity and honesty.

Richard Feynman.

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Some people say, "How can you live without knowing?" I do not know what they mean. I always live without knowing. That is easy. How you get to know is what I want to know.

Richard Feynman.

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I don't know anything, but I do know that everything is interesting if you go into it deeply enough.

Richard Feynman.

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So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies . . . publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education.

William Osler.

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The greater the ignorance the greater the dogmatism.

William Osler.

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The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.

William Osler.

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One of the first duties of the physician is to educate the masses not to take medicine.

William Osler.

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In the fields of observation chance favors only the prepared mind.

Louis Pasteur.

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Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world. Science is the highest personification of the nation because that nation will remain the first which carries the furthest the works of thought and intelligence.

Louis Pasteur.

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Not far from the invention of fire must rank the invention of doubt.

Thomas Henry Huxley.

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The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.

Thomas Henry Huxley.

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The foundation of morality is to have done, once and for all, with lying; to give up pretending to believe that for which there is no evidence, and repeating unintelligible propositions about things beyond the possibilities of knowledge.

Thomas Henry Huxley.

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My business is to teach my aspirations to conform themselves to fact, not to try and make facts harmonise with my aspirations.

Thomas Henry Huxley.

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There must have been a time, in the beginning, when we could have said – no. But somehow we missed it.

Tom Stoppard

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All men can be criminals, if tempted; all men can be heroes, if inspired.

G. K. Chesterton

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There is no such thing on earth as an uninteresting subject; the only thing that can exist is an uninterested person.

G. K. Chesterton

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Good taste, the last and vilest of human superstitions, has succeeded in silencing us where all the rest have failed.

G. K. Chesterton

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Men become superstitious, not because they have too much imagination, but because they are not aware that they have any.

George Santayana

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If we are uncritical we shall always find what we want: we shall look for, and find, confirmations, and we shall look away from, and not see, whatever might be dangerous to our pet theories. In this way it is only too easy to obtain what appears to be overwhelming evidence in favor of a theory which, if approached critically, would have been refuted.

Karl Popper

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It is difficult to get a man to understand something, when his salary depends upon his not understanding it!

Upton Sinclair

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Freedom is what you do with what's been done to you.

Jean-Paul Sartre

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Where goods do not cross frontiers, armies will.

Frédéric Bastiat

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The ultimate result of shielding men from the effects of folly is to ﬁll the world with fools.

Herbert Spencer

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Political language — and with variations this is true of all political parties, from Conservatives to Anarchists — is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

George Orwell

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Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.

John Adams

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We're not presuming the answers before we ask the questions.

Lawrence Krauss explaining how science works

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Malo Periculosam Libertatem Quam Quietum Servitium.

Better freedom with danger than peace with slavery.

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Whatever inspiration is, it's born from a continuous "I don't know."

Wislawa Szymborska

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All sorts of torturers, dictators, fanatics, and demagogues struggling for power by way of a few loudly shouted slogans also enjoy their jobs, and they too perform their duties with inventive fervor.

Well, yes, but they "know." They know, and whatever they know is enough for them once and for all.

They don't want to find out about anything else, since that might diminish their arguments' force.

Wislawa Szymborska.

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Theory helps us to bear our ignorance of fact.

George Santayana

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Miracles are propitious accidents, the natural causes of which are too complicated to be readily understood.

George Santayana.

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Fanaticism consists in redoubling your efforts when you have forgotten your aim.

George Santayana

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There is a fundamental difference between religion,

which is based on authority,

and science,

which is based on observation and reason.

Science will win because it works.

Stephen Hawking.

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The truth, indeed, is something that mankind, for some mysterious reason, instinctively dislikes. Every man who tries to tell it is unpopular, and even when, by the sheer strength of his case, he prevails, he is put down as a scoundrel.

H.L. Mencken.

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It is the natural tendency of the ignorant to believe what is not true. In order to overcome that tendency it is not sufficient to exhibit the true; it is also necessary to expose and denounce the false.

I am attempting to make it easier, when I use footnotes, to navigate to the information in a footnote, look at the information, and return to where you were before you clicked on the footnote. If you click on the number of a footnote in the text[1] <- click on the bracketed and underlined number - in this case [1], it will bring the footnote to the top of the screen.

[1] If you click on the bracketed and underlined number of a footnote in footnote section, the [1] at the beginning of this paragraph, it will take you to where you clicked on the footnote in the text, with the footnote along the top of the screen. [To top of footnotes]

If you wish to modify the size of the text, you can press the CTRL key and roll the mouse wheel forward or back, or you can press the CTRL key and the + or - keys to make text larger or smaller. Another way is to adjust the font in your browser controls.

This is a mostly medical blog, so here is the HIPAA incantation to ward off evil whiny HIPAA-obsessed spirits.

HIPAA (Health Insurance Portability and Accountability Act of 1996) is generally misrepresented by those in health care, but there are no violations of HIPAA here. There are some patients I could not discuss without changing details, so details may be omitted, or changed. That may decrease the dramatic effect of some of what I write, but patients are entitled to their privacy and have been since before HIPAA became the ignorant administrators' justification for imitating a two year old yelling NO!

I am not dispensing medical advice. If you get your medical advice off of a blog, instead of consulting a physician (such as your medical director), you probably should not be treating anyone, not even yourself. I could include your dog, but that would suggest that veterinarians do not provide excellent care. The veterinarians I know take pride in the care they deliver and deliver excellent care, more so than many people I know in EMS.

I do point you to research to support what I write, but you still need to make sure that you have the authorization of your medical director before changing any of your treatments. If your medical director does not agree, you can point to the research I write about. Most doctors do understand research, they just have trouble keeping up with the amount of research that is produced.

What I write does not change your protocols. If you do not like a protocol, take it up with the medical director. I have several inadequate protocols, too. I call medical command and attempt to persuade the physician that what I am requesting is in the best interest of the patient. It is rare that I am turned down, but the dose is often inadequate. I call back before I need more, so the patient does not have to put up with the On Line Medical Command delay in treatment. Health care providers should be anticipating where the care of the patient is headed - both for good and for bad.

I do not have any connection to the products I mention, other than using them and being satisfied, dissatisfied, or some combination of the two. If I have any potential conflict of interest, I will mention it clearly.

If I write about a book by an author I know, I will encourage you to buy the book from the author's web site. This means that any money goes to the author (or to where the author wants the money to go, such as a charity) and you have an opportunity to sample the author's writing for free on the author's blog before buying the book.

I may be blunt, but I do not intend it personally. There are few mistakes that can be made that I have not made. I continue to try not to be stupid; you may conclude that I fail.

I welcome any relevant comments and much that is not relevant. I reserve the right to delete any inappropriate comments. I decide what is appropriate based on my own nebulous standards. Criticism of ideas is expected. Criticism of writing style is appreciated.

I avoid obscenity because I believe that the English language provides enough opportunities for creativity that resorting to the words that may not be said on TV (and a growing group of words that may) is unnecessary. I may quote something that contains some of these words, or I may link to something that does, but that is as bad as I expect to be with these words.

On the other hand, you may feel that the ideas I present are offensive. My aim is to encourage thought, dialogue, and creativity - not to tell you everything is OK. You may leave this blog at any time and bury your mind in comfortable, familiar ideas.

If you feel that the ideas I present are not challenging, please encourage me to address whatever you feel I do not adequately address.